The elimination period in long-term care insurance may mean two different things. First is the time period between when a policy goes into effect and when benefits become available. During this period, the policyholder may not receive long-term care benefits even if they meet the qualifications to do so as outlined in their policy.
The second elimination period in long-term care insurance is a required wait between when you first need long-term care based on your condition and when benefits become payable. Your policy defines this elimination.
Because you may not receive any long-term care coverage during either type of elimination period, it is important to ensure you have another option to cover your cost of living and care, if necessary, during this time.
The Purpose and Use of Long-Term Care Insurance
Long-term care (LTC) insurance is designed to help pay for nursing home or assisted living care if the policyholder may no longer live independently or perform certain activities on their own. Generally, a claimant may be able to qualify for benefits through their long-term care insurance carrier when there is documentation that their medical condition—including both cognitive and physical abilities—prevents them from self-care activities such as:
- Preparing and eating meals
- Hygienic activities
- Taking medication as prescribed
- And more as needed
Many policies require you to be unable to do two or more activities of daily living to qualify, but you should check your policy or the policy of your loved one to understand the qualifications. Once documented, you may be able to file a claim to receive benefits that may help pay for nursing care to help.
However, if you have a new policy, you may need to wait before your benefits kick in. In addition, because these policies primarily cover long-term care needs, there may be another period when you may have to wait to prove your condition is long-term or permanent.
The Process of Getting Approved for Long-Term Care Benefits
When a long-term care insurance policy has an elimination period to prove you require ongoing support, you may likely file your claim during this period. The insurance carrier may want to see your claim and paperwork showing you meet their qualifications for needing this type of coverage.
According to Investopedia, long-term care insurance carriers often require you to prove a set number of consecutive days of needing support before they determine that you qualify for long-term care benefits. Even if you qualify based on your condition, the benefits may not become payable until the elimination period has elapsed.
For example, if your policy has a 120-day elimination period, you may need to be unable to live independently or meet your own self-care needs for 120 days before they begin to pay out for your care.
There May Be Options to Fight a Denial of LTC Benefits
In a perfect world, a policyholder would file for their long-term care benefits during the elimination period, and benefits would begin as soon as they become payable based on the policy stipulations, which is how this process should work, and it does work this way for some people.
For others, however, the process may not go so smoothly. Insurance carriers deny these claims regularly. If this happens to you or a family member, it may be necessary to take action to challenge a denial. You may need to continue to find other means to cover the cost of the required care or have a loved one offer this support while you fight for coverage.
There are several options for fighting a denial of long-term care benefits, including:
- Filing an internal appeal
- Filing a lawsuit and taking the case to trial
- Trying to negotiate an out-of-court settlement
- Other options based on the facts of your case
Our team may be able to help you understand which of these options is available to you and might help get your denial overturned or recover other possible compensation. However, you may need to act quickly. The Limitations Act of 2002, S.O. 2002, Chapter 24 gives us only two years from the date of your initial denial to file suit, and appeals do not extend this deadline.
Discuss Your Long-Term Care Denial with an Injury Lawyer Today
A lawyer from Preszler Injury Lawyers may be able to help you fight a benefits denial. We may be able to get you approved for benefits or otherwise recover compensation on your behalf if you qualify. We serve clients in Toronto and other nearby areas in Ontario. If your condition prevents you from traveling into Toronto to meet with us, we may come to you.
Call (416) 364-2000 today to learn more about our services and how we may be able to help you.